Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study

Ruud G. Nijman*, Kate Honeyford, in association with the REPEM network (Research in European Pediatric Emergency Medicine) as part of the EPISODES study group, Ruth Farrugia, Katy Rose, Zsolt Bognar, Danilo Buonsenso, Liviana Da Dalt, Tisham De, Ian K. Maconochie, Niccolo Parri, Damian Roland, Tobias Alfven, Camille Aupiais, Michael Barrett, Romain Basmaci, Dorine Borensztajn, Susana Castanhinha, Corinne Vasilico, Sheena DurninPaddy Fitzpatrick, Laszlo Fodor, Borja Gomez, Susanne Greber-Platzer, Romain Guedj, Stuart Hartshorn, Florian Hey, Lina Jankauskaite, Daniela Kohlfuerst, Mojca Kolnik, Mark D. Lyttle, Patrícia Mação, Maria Inês Mascarenhas, Shrouk Messahel, Esra Akyüz Özkan, Zanda Pučuka, Sofia Reis, Alexis Rybak, Malin Ryd Rinder, Ozlem Teksam, Caner Turan, Valtýr Stefánsson Thors, Roberto Velasco, Silvia Bressan, Henriette A. Moll, Rianne Oostenbrink, Luigi Titomanlio

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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BACKGROUND: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. METHODS AND FINDINGS: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. CONCLUSIONS: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. TRIAL REGISTRATION: ISRCTN91495258

Original languageEnglish
Article numbere1003974
Pages (from-to)1-27
Number of pages27
JournalPLoS Medicine
Issue number8
Publication statusPublished - 26 Aug 2022

Bibliographical note

Funding: RGN was supported by National Institute
of Health Research, award number ACL-2018-021-
007. The funders had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript.

Funding acquisition: Ruud G. Nijman, Ian K. Maconochie, Damian Roland, Henriette A.
Moll, Rianne Oostenbrink, Luigi Titomanlio.


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